Freddie DeBoer is a prominent writer/thinker from left wing circles. In addition to being a professor of rhetoric and composition at Purdue University he also has a conspicuous online presence. I first read him back in the days when he would guest blog at Andrew Sullivan's old web site, the Daily Dish. His political and social stances certainly lean heavily toward the boilerplate socialistic--- single payer healthcare, better redistribution of wealth, the critical threat of income inequality to civil unrest, high tax brackets to fund greater government programs, a covetousness of the perceived Scandinavian panacea etc. But he also has demonstrated that he is unafraid to take on anyone he disagrees with, even those from the consensus liberal Orthodoxy. His strong opposition to the recent rise of the very illiberal "new PC" on college campuses with its emphasis on rigid speech controls---- trigger warnings and safe zones and various "cultural appropriations"--- has been remarkable and admirable.

But a few weeks ago on Twitter, Dr DeBoer made some unfortunately uninformed remarks regarding the remuneration of physicians in the United States. Let me transcribe a series of tweets he published:

I'm on board with breaking the doctor cartel......Because their professional association artificially restricts the number of people who can become doctors.....The American Medical Association uses its massive lobbying and professional power to artificially restrict doctor licensure.....This in turn leads to the objectively, indisputable fact that American doctors are massively overpaid.....These sky-high salaries, compared to countries with better health outcomes, in turn make US medicine hideously expensive.

So in Dr DeBoer's neat formulation, the powerful AMA uses its considerable resources to prevent Congress from doing anything about the number of medical school admissions. This resultant shortage of doctors leads thereby to increase demand for doctor services. Hence doctors are overpaid. And therefore, the entire American healthcare system is more expensive and less efficient than health care systems in similarly rich, industrialized nations, especially in Europe.

You can make a great summer salad by peeling all your apples and oranges and mixing the slices all together but it's not a great way to spin an argument. Dr DeBoer is aghast that American doctors are more generously reimbursed than their European colleagues. Would he be troubled to know that American college professors are paid more than they are in Europe? Or that nurses average $70k in the United States and $44k in the UK? That the ratio between American CEO to average worker pay is two to three times higher than what it is in European nations? That car mechanics make 30-50% more in the USA vs Europe? It's amazing: the wealthiest nation on earth tends to pay its citizens commensurately more for services rendered.

The United States, additionally, is a more expensive place to live. And although American physicians make more in terms of absolute salary and income, reimbursements have been falling over the past several decades, relative to inflation. As per the paper from Tu and Ginsburg:

Between 1995 and 2003, average physician net income from the practice of medicine declined about 7 percent after adjusting for inflation, according to HSC’s nationally representative 2004-05 Community Tracking Study Physician Survey (see Figure 1and Data Source). Primary care physicians and surgeons fared the worst in keeping pace with inflation, while medical specialists fared the best.

This graphic demonstrates the losses sustained compared with other professional and technical workers in the United States.​

Further complicating Dr DeBoer's argument is the great Cutler paper from 2011 that examined contributory factors in skyrocketing American healthcare costs. Although American doctors are higher paid than their European counterparts, the relative impact of this discrepancy is lessened when the numbers are adjusted for comparative differences in earnings distribution, wealth, and average incomes across the spectrum of OECD nations.

When examining American doctors incomes as a ratio of earnings to GDP per capita, physicians make about 5.8 times what the average American worker earns. This ratio is commensurate with physician pay in Germany, Canada, France, and Australia. Furthermore, if one were to break it down even further and compare American doctors with other "high earners" (i.e. those with incomes in the 95-99th percentile) one finds that American specialists make 37% more than other high earners---which is less than what non-American specialists make compared with high earners in European countries (45%). General practitioners in the United States, on the other hand, actually make only about 90% of what a high income family earns. this number holds steady when compared with non-American OECD nations.

In essence, when corrected for overall national wealth and GDP, American doctors aren't all that different from their European colleagues. The Cutler paper goes on to say that other factors are more contributory to explosive American health care costs--- things like wasteful administration costs, the overall intensity of treatment and overuse of unnecessary resources, the relative higher costs of drugs and medical devices, etc.

Uwe Reinhardt, the eminent Princeton economist, has written that American doctors are not the problem when it comes to spiraling healthcare costs:

Cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.​

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

So 10% of healthcare spending ends up in the pockets of American physicians. Is this a number that needs to be shaved down even more? Is that the solution? That a greater percentage of healthcare spending ought to be redirected to hospital CEO's and Vice Presidents of Patient Satisfaction, Big Pharma, the medical device industry, third party administrators, and the health insurance industry? In addition, DeBoer fails to grapple with exploding medical school tuition costs and the opportunity costs therein. He fails to acknowledge the heretofore gradual and expected worsening decline in physician reimbursements. He doesn't acknowledge the fact that a growing percentage of American docs are accepting positions as employees of giant healthcare behemoths. Further, American doctors often find themselves squeezed by the American tax system, i.e. they make just enough to qualify for the upper brackets but not so much that paying more in taxes affects only whether or not to buy another condo in the Cayman Islands like those who earn 7 figures working in finance or the tech sectors. Not to mention growing physician satisfaction and rising suicide rates....

I hate to be in a position where I am groveling before the public to justify my income. As a general surgeon, I work long unpredictable hours, I deal with ungodly stress and strain, I'm tired all the time, I miss out on a lot of the things I enjoy. But I can't imagine doing anything else. I know what I do has value. This is the life I have chosen. And i knew that going into it. I make more than the average Joe, this is true. I don't want to say I "deserve to" because then you fall down the slippery slope of subjective assessments of who deserves what and how much--- doesn't a good elementary school teacher "deserve" a lot more or an inner city Big Brothers Big Sisters coordinator? etc etc--- but I certainly don't deserve to be smugly admonished as representative of the primary cause of our exploding healthcare cost crisis by a thinly informed intellectual from Purdue.

November and December is always an especially busy time of the year in the life of a general surgeon (attributable to a large extent to the rise of b.s. high deductible insurance plans which everyone seems stuck with nowadays) and so I haven't been able to post much to the blog. But I have been taking notes on some recent developments related to head trauma, football and CTE. Let's get to some of them now.

1) Last week, Vice told the harrowing, heart breaking story of Zack Langston, a 26 year old former high school and college football player who spiraled downward, consumed by paranoia, depression and despair, ultimately taking his own life at the age of 26.

Following his death, Zack's family had his brain studied by the eminent Boston pathologist Ann McKee. The post-mortem diagnosis was confirmed to be Chronic Traumatic Encephalopathy (CTE). The only surprising thing was the extent of pathognomonic tau tangles throughout his brain. According to Dr McKee, the disease was as advanced in Zack's brain as what she found in the brain of 42 year old former NFL star Junior Seau. "It's getting to be pretty common for us to see cases in twenty-somethings", McKee said. Further from the article:

McKee's brain bank found CTE in the brain of Patrick Risha, a former Dartmouth football player who committed suicide at age 32; in the brain of Michael Keck, a high school star who played just one year of college football and died at age 25; in the brain of Joseph Chernach, who played Pop Warner and prep football and committed suicide at age 25; and in the brain of Nathan Stiles, who died at age 17 from a brain injury suffered during a high school football game. In total, McKee says, she has found CTE in the brains of 41 of 50 former college football players her brain bank has examined, and six of 26 former high school players. As part of a proposed settlement of a class action brain trauma lawsuit against the National Collegiate Athletic Association, actuaries for the organization estimate that for a period covering college sports careers beginning between 1956 and 2008, approximately 50-300 former athletes per year will be diagnosed with the disease.

Questions certainly remain. Why are some younger people more susceptible to brain trauma and the development of CTE than others? What triggers this early onset form of the disease? And how can we do a better job of identifying those youths who are at an especially high risk of suffering the consequences of repeated sub-concussive trauma? The National Institutes of Health recently awarded $16 million in grants to physicians and researchers to investigate these questions and to develop better methods of diagnosing early CTE while athletes are still alive, whether using novel imaging techniques or blood tests. None of the $30 million allocated toward research the NFL agreed to pay as part of a class action lawsuit will be used for the studies (per ESPN) because of concerns from the NFL that the researchers will be "biased". Of course they would think that. For years, the NFL's modus operandi has been to attack the credibility of scientists who report objective findings counter to what the NFL would like the public know.

2) Somehow, the disgraced Elliot Pellman is still gainfully employed by the NFL in some capacity related to the health of its players. Recall that Dr Pellman, a trained rheumatologist (?!?!?!), was the chairman of the NFL's Mild Traumatic Brain Committee from the 1990's. This Orwellian "committee" functioned as a mouthpiece for NFL propaganda. Specifically, his group authored a series of 6 peer reviewed articles that trivialized the long-term impact of head trauma of players. Here is a conclusion from a retrospective 6 year study his group published in the journal Neurosurgery:

Evan Murray was a 17 year old high school senior, honor student, and three sport athlete who died last Friday as a direct result of injuries sustained playing quarterback for his school football team. On the last play of his life he got drilled by a defender with a clean hit to the midsection. He gathered himself, rose, and walked off the field on his own. Shortly thereafter, however, he collapsed on the sideline and the on-site ambulance transported him to the hospital. It's unclear what happened next, whether he died en route to the hospital or in the ER or during emergency surgery. He died, though. That much is true. The 17 year old boy died playing a game on a Friday night in his hometown under the lights in front of friends and family.

The worst part is that Evan Murray was not an anomaly. In the past three weeks, 3 high school football players have died from football related injuries. Ben Hamm was a 16 year old kid from Oklahoma who collapsed after a tackle. The impact of the hit caused significant intra-cranial bleeding. And despite the best efforts of local neurosurgeons, he was unable to be saved. Before that, Tyrell Cameron, a 16 year old from Louisiana, broke his neck covering a punt and died on the field from asphyxiation. Three deaths in three weeks. Three teenagers.

Every year 12 boys and young men die playing high school or college football. Doesn't sound like a lot, I guess, in the grand scheme of things. More teenagers and young adults die in traffic accidents over Christmas break than in 20 years of amateur football competitions . And many of those football deaths are more a function of underlying medical issues like cardiac abnormalities or sickle cell disease. But many are directly football related. What if only 6 kids died every year as a result of football injury? Does that make it any better? Is that a number we are all comfortable with? I have a four year old son. The idea of sending him out to play a game in which there is a statistical possibility that he might die on the playing field makes my stomach turn.

And we haven't even mentioned the long term effects of repeated head trauma that football players sustain. Chronic Traumatic Encephalopathy (CTE) is a degenerative disease affecting people who are subjected to repeated concussive and sub-concussive head traumas leading to progressive neurologic decline, dementia, and psychiatric instability. Formerly known as "Punch Drunk Syndrome" when used to describe retired pugilists, the pathophysiology has been well documented and described, especially at Boston University, by neurologists and pathologists studying the brains of selected deceased football players, both from the professional and amateur ranks. Frontline, the investigative arm of PBS, recently reported on findings from Veterans Administration/Boston University researchers that confirmed CTE in the brains of 87 of 91 former NFL players studied and 131 out of 165 men who had played football either professionally or in high school/college. The National Football League recently settled a class action lawsuit brought by thousands of former players suffering from the ravages of CTE for $765 million.

But you object, you say: CTE is a disease of older, retired, broken down NFL players---think Mike Webster, Gene Hickerson, John Mackey--- players who played long ago in a far more brutal, less regulated era. We have high tech helmets now and penalties for spearing and head shots and you can't hit the quarterback after he throws. The game's been cleaned up, you say. There are "concussion protocols"! It's safer! Roger Goodell said so!

But a deep dive into into the mortality data ought to unsettle anyone's false sense of security. You come across the story of Junior Seau, a 43 year old All-Pro linebacker about to be inducted into the Hall of Fame who died from a self-inflicted gunshot wound (intentionally aimed at his chest in order to save his own brain for research). His post mortem revealed advanced CTE. Or what about Andre Waters, the former All-Pro Eagles safety, who put a bullet in his head at age 44? The autopsy of Waters' brain revealed degenerative changes such as one would find in an 85 year old man with dementia.

Or what about Chris Henry, the troubled, often arrested 26 year old Bengals wide receiver, who died after falling out of the back of a pick-up truck during a dispute with the mother of his children? The Brain Injury Research Institute of West Virginia released a report in 2010 confirming CTE in Henry's brain. He had never been formally diagnosed with a concussion.

Or Michael Keck, a former University of Missouri linebacker who died from a heart condition at age 25. Prior to his death he suffered miserably from headaches, memory loss, visual changes, and mood swings. He suspected that "something was wrong" but doctors were unable to diagnose anything specific. His autopsy confirmed CTE.

Or consider the case of 21 year old Owen Thomas, a lineman the the University of Pennsylvania who killed himself in 2010. His autopsy revealed early stages of CTE.

Or how about 18 year old John Doe---his identity kept anonymous at his parents request--- a three sport star who died and had his brain autopsied. The pathognomonic tau tangles of CTE were found in his brain.

Finally, there was the case of Nathan Stiles. Nathan was a 17 year old senior running back for his team in Kansas. He was Homecoming King, a straight A student. He died after sustaining a second blow to his head after a recent concussion. His brain was then sent to researchers at Boston U. who eventually confirmed the presence of CTE. Nathan Stiles was 17 years old and his brain was already manifesting signs of CTE. So far, he has been the youngest person diagnosed with CTE. God willing we don't find anyone younger to beat this ignominious record.

As a thought experiment, imagine someone coming before a school board and proposing that the district adopt a new varsity sport, let's call it Knock-Around (KA). The presenter describes it as a game of skill, strength, and speed. It would foster teamwork, camaraderie, selflessness, he says. The only drawback, he admits, almost as an aside, is that it does carry risk of significant injury. Every year, 10-12 kids will die playing KA, he nearly whispers And dozens more will be maimed and severely injured, even paralyzed. You'll need doctors and ambulances on site in case of emergency. But that hardly ever happens. His affect brightens. The town will love it. It's exciting and manly and would inspire our community to really rally around the boys. Entire weekends would be built around the homecoming KA game!

What would happen? What would a school board tell this enterprising advocate for KA? Get lost? Are you nuts? Are you a sociopath?

Or imagine something less fabulist. What if a community member proposed that boxing was sanctioned as a school varsity sport? It's absurd right? Boxing is awful and barbaric and brutal. The entire point is to pummel someone's brain into oblivion with your fists. Men have actually died in the ring. The image of Muhammad Ali stumbling along as a shell of his former self is always heartbreaking. No parent, even the most martial-leaning, anti-wussification ones would sign off on a school sponsored activity like boxing, right? Way too much liability. But then I started wondering: how many people have actually died in the ring? Off the top of my head, the last death I remember was when Boom Boom Mancini killed Duk Koo Kim back in the 80's. So I found an article from the journal Neurosurgery (2010) that researched the number of boxing related mortalities from 1950-2007. There were 339 deaths directly attributable to an injury sustained in the ring over that time period. 339 divided by 57 is about 6 per year. Remember this was a review of boxing-related deaths in the professional ranks. So half as many grown men die every year boxing compared with the number of teenagers and 20 year old kids who die playing football. Let that sink in for a moment. Twice as many kids die every year on the gridiron.

The end is coming. Football knows it. The NFL just cut a check for $760 million to shut up the loudest voices and delay the inevitable. We can all decide to make that end arrive a lot sooner, though. And maybe save a few lives. Don't let your boys play this game anymore. It's as simple as that. No one wants to read about another Evan Murray in the news next week.

The details surrounding the botched, horrifying execution of Clayton Lockett in the state of Oklahoma can be read in full here (June Atlantic issue). Clayton Lockett had confessed to the grisly murder of a 19 year old woman in 1999. He spent 15 years on death row. By the time all appeals had been exhausted and an execution date set, the process for how capital punishment is carried out in Oklahoma, and in many states where lethal injection is employed, had changed considerably.

As the public appetite for electric chairs and hangings and the firing squad waned, lethal injection became the predominant killing method for states where the death penalty is still legal. It was seen as clean, anti-septic, humane, clinical. No more hooded figures thrashing about strapped down in a chair, rapidly cooking from the inside. No more Wild West public hangings. No more Gulag-style firing squads with criminals lined up against a graffiti-littered wall. It was a neater, cleaner, more "civilized" way for the government to go about ending a human's life. A clean quiet white room. Medical personnel in white masks. The beeping of a monitor indicating heart rate and oxygen levels. An IV inserted adroitly in the forearm. Then, a series of three drugs, infused in quick succession. One to anesthetize, one to paralyze, and then the killer--- high dose potassium chloride to stop the heart. Bing, bang, boom. The convict lies sedately on a flat white bed. His eyes close. He seems to be sleeping. And then the rhythm monitor goes flat. He is pronounced dead. The state has completed its act of retributive justice. We can all go home feeling satisfied.

But not all is always as it seems. Sometimes things don't go as expected. In the United States, it has become very difficult for states to acquire the preferred sedative, sodium thiopental, due to international pressures on pharmaceutical companies who produce it. You see, the countries where capital punishment occurs with the highest frequency are: China, Iran, Iraq, Saudi Arabia, Somalia, and..... the United States. This is not a collection of nations one would ordinarily like to find oneself grouped. The United States, paragon of freedom and liberty and western civilization, executes more people than all but a few repressive, authoritarian regimes. The drug giant Hospira, the only FDA approved distributor of sodium thiopental, no longer sells its products to states for use in executions. The European Union outlawed export of drugs to be used in lethal injections in 2011, thereby forcing states to adopt more creative methods. Our nation has staked out a position on an island, morally and ethically. We kill our criminals. The rest of the advanced world has deemed the practice barbaric and backward.

My original intent was not to make this an anti-death penalty rant (although perhaps that is the way it is trending). My intention is to focus on a specific aspect of how the death penalty is carried out in general, and the Clayton Lockett execution in particular. To wit, what is the role of a physician in all this? The American Medical Association (AMA) statement on capital punishment and the practicing physician is as follows:

An individual’s opinion on capital punishment is the personal moral decision of the individual. A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution. Physician participation in execution is defined generally as actions which would fall into one or more of the following categories: (1) an action which would directly cause the death of the condemned; (2) an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned; (3) an action which could automatically cause an execution to be carried out on a condemned prisoner.

The AMA, of course, has no legal authority to punish or discipline any doctor who chooses to violate this dictum. It cannot suspend medical privileges or revoke state licenses. It is simply a clarification of expected physician conduct, an elucidation of a code of ethics to guide physician behavior. Violations are violations of spirit, not of law. The American Board of Anesthesiology, actually stepped up in 2014 and incorporated the AMA code of conduct into its own professional standing policy. This actually has some teeth. Anesthesiologists who actively participate in executions run the risk of having board certification status revoked. Many hospital systems will only credential and issue privileges to board certified physicians. No privileges = no income. For all other specialties, however, the AMA directive on capital punishment is essentially an elective guideline. State medical boards have historically not taken action against physicians who involve themselves in state executions. No physician in America has ever had her state license suspended or revoked due to actions related to an execution.

The case of Johnny Zellmer, MD bears scrutiny. Dr Zellmer is listed as a family practice physician in Oklahoma City, Oklahoma. He has been in practice 15 years and the Lockett fiasco was the second execution where he had been present. In general a physician is retained on the day of an execution in order to legally pronounce death. As per AMA guidelines, physicians are not expected to participate in the actual killing mechanism. But that's not the role Dr Zellmer chose to fill that day. After numerous failed attempts to gain IV access, the paramedic in the death chamber called for assistance. Inexplicably, Dr. Zellmer responded to her call. He tried to get an IV in Lockett's jugular vein. He tried several times to get a triple lumen catheter in his subclavian vein. He asked for the availability of an intraosseus needle. Then he moved to the groin. They had been trying to get an IV into Lockett for an hour. For some reason he used a standard short length (1.5 inch) angiocatheter to obtain access to Lockett's femoral vein (generally we like to insert 5-8 inches of catheter length into the access site) . Lockett was covered in drapes and the execution commenced. Unsurprisingly, the catheter retracted out of the vein and most of the infused drugs went into Lockett's subcutaneous fatty tissue instead of his vascular system. No one noticed this right away. After infusion of the death cocktail, Lockett was still able to speak and move. Dr. Zellmer then entered the chamber, pulled back the drapes and noticed a giant swelling in the groin where the IV had been placed; unmistakable evidence of subcutaneous infusion. So Zellmer then decided to place another line in the opposite groin. He hit the artery instead of the vein and called for more drugs to be administered. The paramedic demurred, insisting that he must access a vein. He pulled the catheter from the artery. He held pressure. Blood was all over the drapes. Chaos reigned. No one knew what to do. Zellmer and the paramedic briefly considered the idea of resuscitating the still alive Clayton Lockett with CPR. An emergency phone call was placed to the governor's office. Permission was granted to halt the execution. But by that time, enough of the lethal cocktail had been absorbed through his subcutaneous tissues that his breathing and heart rates slowed and eventually stopped. He was declared dead an hour and a half after the initial attempt to gain IV access. It was a long, slow, agonizing death.

Dr Johnny Zellmer participated in the execution of an inmate last year in Oklahoma. This is undeniable. Without Zellmer's intervention, no matter how incompetent or maladroit it may have been, Clayton Lockett would not have died that day. The estate of Clayton Lockett has filed a lawsuit naming Dr Zellmer as defendant for 8th amendment violations. It is highly unlikely that this will amount to much. But I think this is a case where our profession needs to keep its own house in order. We need to make sure an episode like this never happens again. I think the AMA ought to publicly censure Dr Zellmer by name. Area hospitals where Zellmer may practice ought to consider this event when evaluating him during the credentialing process. The state medical board of Oklahoma has the authority to determine his eligibility for license renewal. At minimum, a suspension of his license seems appropriate. From my perspective, Johnny Zellmer, due to his actions on April 29 of last year, has forfeited his privilege to call himself "doctor" for the rest of his days.

Now that a lot of the hullabaloo surrounding ProPublica's release of their "Surgeon Scorecard" last week has died down I thought it would be a good time to take a step back and assess things pragmatically. ProPublica did a disservice both to American patients in need of guidance, and to practicing surgeons. That much is undeniable. The "best" defenses I have heard for the scorecard is that it was "a good start" or a "first step forward on the road to transparency" or"Bob Wachter thought it was just great!" or the remarkably inane, "it's better than nothing!"

In a previous post I outlined the flaws and derivative inconsistencies in the methodology used to compile the Scorecard. And I am not alone in my lack of enthusiasm; the overwhelming consensus opinion from surgeons and physicians across America has been strongly negative. Even the American College of Surgeons has weighed in, submitting the following op-ed to the Washington Post (unpublished as of today):

Surgeon ratings need to be a shared responsibilityThe American College of Surgeons strongly believes that patients and their families deserve to have meaningful information available to assist them in selecting the right surgeon. This week, two public interest groups launched websites promising to assist with surgeon evaluation. Unfortunately, the usefulness of the information they shared is questionable for a number of reasons.The two groups used differing methodologies, including how many years of Medicare data they reviewed, procedures studied, and rating scales used. A patient who visited both websites could potentially find the same surgeon rated very differently or only find a surgeon on one of the two websites.Use of clinically validated data would have more fully taken into account the severity of the patient’s condition when assessing surgeon performance. For example, an 80-year-old diabetic patient with heart disease undergoing a gall bladder removal faces many more challenges than a healthy 40-year-old undergoing the same operation. Without factoring in surgeons’ success rate with the more challenging patients, the potential for wrongly directing patients away from these surgeons certainly increases. And as troubling, some insurers might restrict access to these surgeons in the future.The importance of relying on clinical data to accurately measure surgeon performance is well documented in scientific literature, and clinical registries are considered the standard for collecting this information. As recently as this year, this point was underscored in a peer-reviewed article by Lawson et al in the Annals of Surgery.Collection and dissemination of accurate clinical data, however, is a shared responsibility because it is a labor- and cost-intensive process. Private payors, government, professional societies, and public interest groups—all of whom are invested in transparency—must share this responsibility.Two other issues bear consideration. First, surgery is a team experience. The surgeon works closely with the anesthesiologist and surgical nurses during an operation. While using clinical data can get us closer to measuring surgical performance, the reality is that in the operating room, many factors and many individuals contribute to the surgical outcome. Rating a surgeon’s skill in performing a particular operation, without factoring in these other considerations, leads to an incomplete analysis.Second, we must ask ourselves how much data is helpful to a patient’s decision. The American College of Surgeons fully supports sharing the right data with the right person at the right time. We are open to collaborating with other stakeholders, including those in the public and private sector to identify the data that will serve the public interest.At its core, the American College of Surgeons is committed to improving the care of the surgical patient and believes that sharing meaningful data is key to that endeavor. Let’s do it right and together.

The most influential physician in modern times on data analysis, physician transparency, patient safety and quality control---Peter Pronovost MD, PhD, director of the Armstrong Institute of Patient Safety and Quality at Johns Hopkins--- has this to say about it:

The ProPublica measure is not valid. Though the methodology does account for some of the potential biases that might unjustly influence findings, it fails to account for another significant bias. For the ProPublica method to be a valid measure of surgical quality, all patients facing a potential readmission should have the same probability of being readmitted. Only then could readmission rates serve as a surrogate for complication rates and thus surgeon quality.But patient factors such as their social support system, physician factors such as willingness to accept risk, and factors effecting access to care such as the presence of observation units or care in the emergency department, all impact whether a patient will be readmitted. Indeed, CMS has stopped reimbursing hospitals for admissions lasting less than two days because they recognize that the decision to admit a patient is arbitrary and that many of the same patients could be managed under observation.The Methodology Needs Improvement: Even with these adjustments to the model, like any new quality measure, this would need to be tested and validated before it should be presented as a valid tool intended to assist consumers in their medical decision-making. In summary: the model uses an indirect measure of complications that fails to properly account for the variation in the reasons for a readmission.

The Scorecard was a disaster, in terms of validity, usefulness, and presentation. That we can all agree. But the core nugget of truth that led to its creation-- that patients ought to be able to have relevant and reliable data metrics at their fingertips when going about the process of choosing a surgeon--- remains unsolved. I believe we can create a Scorecard. Scorecard 2.0 if you will. Now I don't know enough about hip or knee replacements or prostatectomies to comment on how go about assessing quality for those procedures but I do know a thing or two about gallbladder surgery, laparoscopic cholecystectomy.

Here's what I would do:

Mandatory reporting for all cholecystectomies performed in the United States. Then divide into elective vs emergent procedures

Data on common bile duct injuries, unexpected bile leaks, and intra-operative deaths compiled for every surgeon and made available publicly. Those surgeons who exceed expected complication rates would be red flagged.

Higher than expected rates of conversion to open cholecystectomy, although not considered a "complication" by surgeons, would be published as an indirect indicator of surgeon skill

30 day readmissions could be included as part of it, but only if the data is analyzed by practicing surgeons in order to exclude those admissions occurring due to unrelated medical issues.

Surgical site infections (SSI's), although not as useful in the realm of minimally invasive procedures, is always a reasonable, objective metric to include

Surgeons who perform a higher percentage of emergent or urgent laparoscopic cholecystectomies could be highlighted as potentially more technically adept, assuming complication rates are equivalent to those surgeons who tend to perform more elective procedures.

Not only should the data be compiled and published, but there ought to be internal review process (perhaps run in concert by the American College of Surgeons and the American Board of Surgery) wherein those surgeons who exceed expected complication rates would be required to undergo remedial training or have their next 20 cases proctored via video analysis. Failure to comply would potentially result in revocation of "board certified" status.

These are just random ideas from a nobody general surgeon in Cleveland. I am sure colleagues at the higher levels of my profession would have plenty of useful insight as well. We all have emails and published office numbers. The next time Marshall Allen et al. want to put together another physician evaluation tool, they can always reach out, drop us a line. We'd be happy to assist.

With much hype and fanfare, the independent investigative journalism outfit, ProPublica this week released their so-called "Surgeon Scorecard", assessing individual specialist surgeons who perform elective knee and hip replacements, spinal surgery, prostate surgery, and gallbladder removal surgery. I had blogged about the impending release last week. My trepidation about the idea of a non-medical, non-scientific organization analyzing complex surgical data concerned issues such as patient accrual, exclusion/inclusion criteria, definition of terms, and the method of analysis that would be utilized. Alas, none of these questions were satisfactorily answered. Nothing about the scorecard really works very well. It distorts reality, clouds data, confuses patients, and proffers no insight in how a surgeon might improve his/her results. It essentially presents meaningless, poorly powered raw numbers in the form of fancy statistics and charts (to be elucidated shortly). The collective response from the community of practicing surgeons has been "what the hell is this?". Even some members of the journalism guild have questioned the validity of the findings--- one going so far as to assert that ProPublica committed "journalistic malpractice" and should retract the piece. That's not for me to say. But let's break a few things down.

First, there are loads of problems with the methodology. The entire data base is composed of Medicare billing records for in-patient only hospital stays from the years 2009-2013. This is a red flag from the start for two reasons. One, it excludes outpatient Medicare cases. It excludes Medicare patients admitted through the ER. It excludes the vast numbers of patients with private health insurance. Two, and most glaringly concerning, the entire analysis of "surgeon quality" was based entirely on billing records. There was no case-specific analysis. No chart review. This may not have been possible given HIPAA and availability of data to journalists but it is a critical weakness. Conclusions were based solely on ICD and DRG codes, context-free. This is like determining the best baseball player in America by evaluating batting average alone, independent of any and all context, and finding out that the award has to be given, not to Mike Trout, but to an 11 year old boy in Huntsville, Alabama who bats cleanup and plays shortstop for his summer travel team because he finished the season hitting at a .744 clip, with 14 homers to boot.

I can't reiterate enough the paucity of data that is analyzed. Laparoscopic cholecystectomy (LC) is generally either an outpatient procedure performed on a patient between the ages of 20-60 or it is done semi-urgently on a patient admitted through the ER with acute cholecystitis. Both of these scenarios would be excluded from the analysis pool. What's left is a tiny proportional sliver of the total actual LC's performed in this country as the basis upon which to judge and assess quality. It's just silly. I'm a practicing general surgeon in Cleveland, Ohio so of course I spent some time reviewing the data on LC in my area. What I found was both ridiculous and inexplicable. If you try to find the LC complication rates of surgeons who operate at the main campus of the Cleveland Clinic you will only find one surgeon listed who qualifies for analysis (a minimum of 20 procedures performed over the 5 year time period). At University Hospitals main campus, there are zero surgeons who made the cut for analysis. So, at the mother ship hospitals for the two massive health care providers of Northeast Ohio, there is apparently only one surgeon who did enough LC's to qualify for the "Surgeon Scorecard". I mean, didn't an editor at ProPublica find this odd, that the Cleveland Clinic allegedly doesn't do enough LC's to qualify for the scorecard? I use to operate a good bit at the east side community hospital Hillcrest. The two busiest general surgeons there from 2009-2013 also don't qualify. None of it makes any sense.

We also have to talk about boring statistical terms like "confidence intervals". ProPublica uses a 95% confidence interval when presenting their data. Given the relatively low number of procedures performed, the results of many surgeon's ratings often straddle two, and sometimes three, categories (low, medium, high) of complication rates. As ProPublica itself admits:

There is a possibility that a surgeon whose adjusted complication rate is “high” might be equivalent to a doctor listed in the “medium” category. The further apart the doctors’ rates stand, the less probability there is of an overlap.

When I reviewed my data, I found that my "risk adjusted complication rate" was 4.2%. (For what it's worth, my complication rate was "better" than all but one surgeon in the Cleveland area-- hooray, I guess) I don't really know what to make of that 4.2 as a raw number but when you account for the 95% confidence interval, it is just as likely, based on the shaded areas of the CI that I could be either a low, medium, or high complication surgeon. So...... I could be good or bad. I could be medium. In fact, all surgeons in the Cleveland area who perform LC's and qualify for assessment fall within a rather narrow complication rate band of 4.1-5.5%. But then the confidence intervals scatter the results of Cleveland surgeons all over the board of low, medium, high. What is a patient to do with such unreliable, discordant information? How does this help an anxious patient make an informed decision? Nothing is gained. Nothing is learned. It's like you're 19 again and some girl broke your heart; all is meaningless, full of sound and fury, signifying nothing.

Another troubling aspect to the scorecard is the rather arbitrary way the term "complication rate" is defined. Per ProPublica, a surgeon gets dinged if one of two things occur: the patient dies during the same admission when the surgery was performed or if the patient is readmitted within 30 days of surgery and a panel of doctors determines that the readmission was "related to the surgery". This is terrible on multiple levels. The 30 day readmit criteria is not clarified. We don't know what factors were considered. We are simply told that "a panel of physicians" determined whether a readmission was "related" to the recent surgery. The word "related" is doing a lot work in that sentence. So the 84 year old patient 3 weeks out from hip replacement who is admitted through the ER with "increasing confusion" due to insomnia and overuse of narcotic pain meds is a red mark against the orthopedic surgeon. Urinary tract infection 2 weeks after spinal surgery in a patient with known BPH. The anxious 27 year old lady readmitted at midnight 2 days after a LC because of refractory nausea. The 49 year old male who develops chest pains 10 days after lumbar fusion surgery. All these are reportable offenses that don't necessarily have anything to do with the quality of said procedure performed.

Most appallingly, these minor events are categorized in the same vein as a freaking peri-op death when assessing individual surgeon quality. So a surgeon who has a tendency to operate on older patients and subsequently sees a higher percentage of his patients readmitted with tangentially related minor medical issues could conceivably have a higher "adjusted complication rate" than a true hack surgeon who kills a few otherwise healthy patients every year. Furthermore, why does ProPublica exclude all complications that occur during the surgical admission except death? Why is "return to OR" not there? What about post operative hemorrhage and need for transfusion? What about a surgeon who all too regularly whacks a common bile duct and transfers the patient immediately to a tertiary care center where it is promptly repaired and the patient never gets readmitted? What about an orthopod who is careless about post op DVT prophylaxis and sees an unacceptable level of blood clots and pulmonary embolisms on his patients? What about surgical site infections? Why is death the only metric deemed appropriate for inpatient quality assessment? It's really an embarrassing lapse in judgment and methodology.

You see, surgeons across America are not afraid of transparency. Cardiac surgeons have had to publicly report their CABG results for years. The American College of Surgeons has made transparency and quality improvement a focus of inquiry. Justin Dimick MD at Michigan and Karl Bilimoria MD at Northwestern and Conor Delaney MD at UH Case Medical Center are doing yeoman's work getting some of this complicated data into peer reviewed journals. Through initiatives such NSQIP and PQRS reporting, the College has begun the long, arduous process of quality-assessment to ensure that patients and payors are presented with data that are accurate, comprehensive, and fair to surgeons. ProPublica calls out a urologist at Johns Hopkins, one of our elite tertiary care centers, for having a higher complication rate than some of his colleagues, without accounting for any mitigating factors. What's his patient population? Does he tend to operate on sicker patients? How many did he do? What exactly were his so-called "complications"? Did he perform a lot of "re-do" or revisional surgery? None of these critical, enlightening factors are considered by Marshall Allen et al. They wanted to get their story up on line ASAP. They wanted to be first, which is a fundamental principle that drives a lot of modern journalism, but isn't so useful when it comes to presenting highly complex, scientific data to the general public. You can't just vomit up a thin sliver of data based on a select cohort of patients and arrogantly title your findings "Surgeon Scorecard" as some sort of definitive, go-to patient resource. And by releasing an article on Dr Constantine Toumbis, a spinal surgeon in Florida who apparently has a higher than normal complication rate and was recently discovered to be an ex-felon dating back to a stabbing incident 20 years ago while a medical student, as a companion piece to the "Surgeon Scorecard", ProPublica veers precipitously close to the yellow journalism of Horace Greeley and Gawker and the New York Post. It's a low moment for an otherwise esteemed investigative operation that has been deservedly recognized for its work in exposing corruption, deceit, and greed across a wide range of subject matter. But this project is no good. We all know that the worst surgeons are either too tentatively slow or way too reckless and fast. ProPublica rushed this study to print without doing the due diligence of vetting it with actual surgeons who are actively attempting to perform the exact same task of assessing and improving surgical outcomes. There are no short cuts to this. It will take some time. It's complex. It will take some twisting of arms within the surgical community. But it's coming. No longer will we as surgeons be able to hide behind our surgical masks or the "MD" certificate hanging on our office walls. We will have to demonstrate proficiency and excellence. I am confident that most board certified surgeons in this country are unafraid of such a proposition. As long as it's done the right way......

Bilimoria, et al have an interesting paper up on JACS (on line only for now) that attempts to quantify the effects of surgical resident work hour reform on patient morbidity and mortality.

Study Design: Patients from 5 surgical specialties (neurosurgery, obstetrics/gynecology, orthopaedic surgery, urology, and vascular surgery) were identified from the American College of Surgeons NSQIP. Data from one year prior and two years after the reform was implemented were obtained for teaching and non-teaching hospitals. Hospital teaching status was defined based on the percentage of operations with a resident present intraoperatively. Difference-in-differences models were developed separately for each specialty and adjusted for patient demographics, comorbidities, procedural case mix, and time trends. The association between duty hour reform and a composite measure of death or serious morbidity within 30-days of surgery was estimated for each specialty.Results: The unadjusted rate of death or serious morbidity decreased during the study period in both teaching and non-teaching hospitals for all surgical specialties. In multivariable analyses, there were no significant associations between duty hour reform and the composite outcome of death or serious morbidity in the two years post-reform for any surgical specialty evaluated (neurosurgery: OR 0.90, 95% CI 0.75-1.08, P=0.26; obstetrics/gynecology: OR 0.96, 95% CI 0.71-1.30, P=0.80; orthopedic surgery: OR 0.95, 95% CI 0.74-1.22, P=0.70; urology: OR 1.16, 95% CI 0.89-1.51, P=0.26; vascular surgery: OR 1.07, 95% CI 0.93-1.22, P=0.35).

In 1984, an 18 year old college student named Libby Zion died less than 24 hours after being admitted to New York Hospital. Her father was a prominent NYC attorney and her mother a former publishing executive. An investigation revealed that Ms Zion died as a result of a deadly medication interaction. She had presented to the hospital ER with several days of flu-like symptoms, including fevers and a tremor. Her medical history included depression, anxiety and substance abuse (toxicology screen was positive for cocaine metabolites). Her psychiatrist had prescribed the anti-depressant Nardil (phenelzine). Her initial ER records indicated a temperature of 103.5, an elevated WBC, and "hysterical symptoms". She was then admitted to the floor at 2AM and evaluated by an intern and a 2nd year medical resident. The working diagnosis was "viral syndrome". For increased agitation and shivering, she received an intra-muscular injection of demerol. Her mental status deteriorated even more; increased confusion and thrashing about in her bed. Soft restraints were ordered and she received a dose of the anti-psychotic Haldol. By 6am her temperature had spiked to 107. Shortly thereafter she went into cardiac arrest and was unable to be revived.

It was revealed that the resident and intern on call that night were finishing out a 36 hour in house shift. An autopsy confirmed that Ms Zion had died from serotonin syndrome, arising from the lethal combination of phenelzine, demerol, and the cocaine abuse. Mr Zion launched an offensive against the hospital, the residents involved in the case, and the entire medical resident training paradigm. He was convinced that the long, unregulated work hours of the residents directly contributed to his daughter's death. Criminal proceedings were considered but ultimately a grand jury declined to indict for murder. At civil trial, a jury found for the Zion estate that the physicians involved in the case were negligent and a $375,000 settlement was ordered to be paid to the Zion family for "pain and suffering."

Afterwards the New York State Health Commissioner established an ad hoc advisory committee, led by Bertrand Bell MD, tasked with evaluating the training and supervision of residents in the state of New York. This "Bell Commission" then formalized a set of guidelines that was implemented by residency training programs in the state of New York in 1989. Specifically, it was mandated that residents could not work more than 80 hours in a week. Over the course of the next 15 years, the idea of work hour reform seeped into the national consciousness and, in 2003, the ACGME enforced the 80 hour work week nationwide, with residents being limited to no more than 30 consecutive hours of continuous duty. By the 2011, the reforms were further revised. Interns are now not allowed to work more than 16 hours continuously and there is some nonsense in there about senior residents being forced to take naps if on call for a 24 hour period.

The impact of work hour reform has been hard to quantify. Theoretically it would see to make sense--- less tired residents would be more attuned to detail, less likely to make errors. Further, putting more onus of responsibility on the shoulders of senior residents and Attending physicians would presumably lead to fewer errors, better patient outcomes. The data from numerous studies, however, has been less than compelling. This, this, this, this, this, and this all magnify the conclusions drawn from the above referenced Bilimoria paper----work hour reform has had no appreciable impact on patient outcomes. Keeping trainees out of the OR, sending them home, forcing them to take naps----none of it has improved patient morbidity or mortality. Not to mention the unforeseen consequences of resident hand-off errors and the still yet to be quantified impact on the quality of medical and surgical training.

But we really ought not to be too surprised. Libby Zion died tragically at the too young age of 18. She died in a hospital, under the watchful eye of two inexperienced, overworked residents. But her death may have been unavoidable. Serotonin syndrome was a poorly understood mechanism back in 1984 and the interaction between phenelzine, demerol, and cocaine was even less well recognized. After the Grand Jury indicted the resident and intern for "gross negligence" the Hearing Committee of the State Board for Professional Misconduct investigated the charges over the course of 30 hearings. Several of the witnesses were Chairmen of Internal Medicine Departments at prominent medical schools who, under oath, testified that they had never heard of the interaction between demerol and phenelzine prior to the Zion case. The initial autopsy, for gods's sake, listed cause of death as "bronchopneumonia". The cause of death was a true medical zebra. Most of the best medical minds of the time would have missed it, well rested or otherwise.

The non-profit independent investigative journalism organization ProPublica has announced plans to release a "Surgeon Scorecard" next week. From the statement:

Millions of patients a year undergo common elective operations – things like knee and hip replacements or gall bladder removals. But there’s almost no information available about the quality of surgeons who do them. ProPublica analyzed 2.3 million Medicare operations and identified 67,000 patients who suffered serious complications as a result: infections, uncontrollable bleeding, even death. Next week, we report the complication rates of 17,000 surgeons – so patients can make an informed choice.

This will be interesting to see. Many questions immediately spring to mind, however.

Will this just be a massive data dump without any attempt at analysis by knowledgeable medical practitioners?

Will there be an attempt to correct for patient factors like age, pre-existing medical conditions, degree of overall health at the time of surgery?

Will the data break down the cases into elective vs emergency operations?

Will they account for surgeons who provide a majority of care to lower income and Medicare/Medicaid patient populations vs those who only rarely operate on patients with subsidized healthcare?

How will they define terms like "post operative sepsis" and "complication rate"? Who decides on whether or not to categorize an outcome as "good" or "bad".

I remain wary of the coming publication, of course. I'm willing to suspend judgement until I get a chance to review it but I think all surgeons are a little anxious about having a third party, non-medical organization present some sort of definitive, simplified "Surgeon Scorecard" (with A's and B's and F's???) to describe a complex data set for the general public.

I think we as surgeons dropped the ball on this by not being more pro-active in responding to public demands for greater transparency in all professional fields. We could have gotten involved early, to ensure that what is presented to the public as an evaluation tool is accurate, fair to surgeons, and reliably instructive in guiding patient decision making. With ProPublica going solo on this, we have lost the ability to mold the narrative.

The Journal of the American College of Surgeons (JACS) has an article this month that I missed last fall, originally presented at the Western Surgical Association meeting in California, that explored differences in outcomes of patients with a bowel obstruction who were admitted to either a medical or surgical service.

This takes me back to my Chicago residency days and fond memories of arguing with ER Attendings at 3 AM regarding whether or not the next name on my endless deluge of consults ought to be admitted to surgery or medicine. It got so bad, administration from both the medical and surgical departments had to articulate actual policies on who would admit certain diagnoses. All bowel obstructions went to surgery. Cellulitis to medicine. Cholecystitis to surgery. Cholangitis to medicine with immediate surgery/GI consults. Pancreatitis could go either way. Mild alcohol pancreatitis went to medicine but severe gallstone pancreatitis with a lot of Ranson criteria had to go to surgery. This eliminated a lot of the unhealthy inter-departmental bickering and resentment. But that was a large academic teaching hospital. You could set policies and make residents do what you want. In the world of private practice and community hospitals it's different. I found that many of the cases I had been forced to take on my service as a resident were now being admitted to medicine with surgery consults. I'd get phone calls at 3 AM from laid back, bro-talking ER docs telling me about so and so with a "hot gallbladder" who was being admitted to Dr Johnson and he was hoping I would consult first thing in the morning. Hell yeah, I said. I'm all for that. The reason for the shift soon became clear. Old school medical doctors who take a lot of ER call actually like having a lot of patients on their primary service. Because they have mortgages and car leases and private school tuition to pay. Plus many of them were actually awesome doctors who saw their patients no matter where they needed care and demanded that, if one of their patients was admitted to the hospital, they were notified and had the patient admitted to their own damn service. I liked those guys.

Results: Median LOS among patients whose ASBO resolved nonoperatively was similar for those on SS and MHS (2.85 days vs 2.98 days; p = 0.49). In patients without nonoperative resolution of ASBO, those admitted to MHS had longer median LOS when compared with those admitted to SS (9.57 days vs 6.99 days; p = 0.002) and higher median charges ($38,800 vs $30,100; p = 0.025). Patients admitted to MHS who had an operation, had a greater median TTO than operative patients on SS (51.72 hours vs 8.4 hours; p < 0.001). Multivariate analysis did not identify factors independently predictive of increased LOS, TTO, or charges.Conclusions: Adhesive small bowel obstruction patients are treated in a heterogeneous fashion in our hospital, causing disparate outcomes depending on admitting service when patients undergo operation. Admitting all suspected ASBO patients to SS has the potential to dramatically decrease LOS and reduce waste in those requiring operation, thereby reducing health care expenditures.

NB: MHS = medical hospitalist service, SS = surgery service

The claim is that patients with a primary diagnosis of a small bowel obstruction who end up requiring operative intervention spend more time in the hospital and accrue higher overall hospital costs. Ergo, in order to save costs and get patients home faster, all bowel obstruction cases ought to be admitted to a surgical service.

Several issues here. First, there was no difference in hospital length of stay in patients who resolved their bowel obstructions with conservative management. Which is good, right? But they found that in those patients who required surgical intervention for refractory obstruction, the patients initially admitted to a surgeon's service had an operation quicker and therefore were discharged from the hospital sooner. But are they neglecting selection biases here? In my experience, the patient with a bowel obstruction admitted to a medical service is more likely to be elderly and have multiple co-morbidities (CHF, CAD, DM, COPD, anti-coagulation medicines etc etc). So the ER calls the surgeon at 4 am. Surgeon tells the ER to place NG, start some fluids, and admit to medicine for optimization of medical issues. Surgeon sees patient first thing in the morning and every day thereafter. This is exactly what he would do whether he was the admitting doctor or a consultant. Furthermore, most surgeons are going to treat a more frail/elderly/unhealthy patient a hell of a lot more conservatively before they decide to recommend surgery (assuming the absence of peritonitis/acute abdomen, of course). An 84 year old patient with severe CAD is probably going to get an extra day or two of NG decompression before you whisk her off to the OR. That isn't delayed intervention due to primary service mis-assignment. It's smart clinical judgment. Conversely, the 46 year old lady with no medical problems gets admitted to surgery no questions asked. And if her films are crap in the morning there's a damn good chance she gets added on to OR that afternoon.

Overall, there was no difference in mortality or major morbidity in the two groups. Readmission rates were the same. The paper simply affirms something all us in clinical practice already know. It really doesn't matter whether the patient gets admitted to Dr. Medicine or Dr. Surgery. As long as the surgeon is notified from ground zero and allowed to follow/manage the patient from the very beginning of admission-- either as admitting physician or consultant---then outcomes will be optimized. It's almost unheard of for a patient to be admitted to medicine without a concomitant surgical consult. The paper tries to imply that the patients admitted to the medical service had a delay of surgical intervention because the surgeon was not consulted for an opinion until too much time had elapsed. But they don't document this. It's a major weakness in the paper.

As far as I'm concerned, as long as you let me know a bowel obstruction is in the ER, you can admit him to the psychiatry service for all I care. I'll manage the patient the same way as always.

This is a silly, uninformed tweet, desperately grasping on to a sliver of fact and distorting the complex reality. Oh so ironic for such a self-declared champion of science and empiricism as Mr Dawkins. He links to an article on the Huffington Post that misleadingly equates the Ramadan fast with a diabetic Muslim man who ended up losing his toe. Lifelong diabetics, especially those who do not control their blood sugars well, are at risk for peripheral neuropathies and vascular insufficiencies, especially of the smaller vessels supplying the feet and toes. This can result in gangrene of the toes and festering, non healing ulcers of the feet. It is an accumulatory, life long complication of decades of sustained, uncorrected hyperglycemia. Of course, Dawkins grabs this rope of opportunity and rides it all the way to Islamophobia-ville. His conclusion is based on a fundamental misunderstanding of how diabetes affects human physiology.

The patient in question did not lose his toe because he had fasted during Ramadan. There is a danger in fasting for diabetics. But it has nothing to do with gangrenous feet and the lopping off of toes. If you fast, have diabetes, and you are taking either insulin or oral hypoglycemics you run the risk of hypoglycemia, or low blood sugars. Profound hypoglycemia can lead to a comatose state, even death if left untreated. The neuropathic and vasculopathic complications of diabetes are the accumulative result of years and years of hyperglycemia. In the context of Mr Dawkins' tweet, this is an important distinction. During Ramadan, a devout diabetic who fasts increases his risk of hypoglycemic coma, seizures, sudden death. What demonstrably won't happen is that his toes will suddenly become necrotic and require an emergency amputation.

This is pure dissembling exploitation. This is donning the false mantle of Scientist Sage strictly for the purpose of scoring points in an ideological crusade. He is not looking to illuminate or unveil hidden knowledge. It is choosing ideology over empiricism. Dawkins has fallen prey to the very logical fallacy that he accuses his theistic foes of committing everyday. He would rather bend reality or willfully misunderstand facts if the empirical results do not support a pre-determined conclusion.

Like many practicing general surgeons I read with interest the recent Finnish paper published in JAMA that attempted to challenge the long held surgical dogma that the best treatment of acute appendicitis is cold hard steel. The paper itself, in terms of design, was beautiful. This was no retrospective review of a series of case studies. This was a rigorously conducted multi-center randomized controlled trial that assigned 530 patients over the course of 3 years into either surgical or non-surgical treatment arms:

InterventionsPatients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy.

Main Outcomes and MeasuresThe primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period.

The results revealed entirely expected findings. Surgical removal of the appendix had a 99.6% success rate. Medical treatment, on the other hand, failed 27.3% of the time (i.e. patient needed to undergo subsequent salvage surgery within the one year follow up period). To an actual general surgeon like myself, the findings are completely unsurprising. The stupefying part has been the response of the general public to the study. In the NY Times we have Gina Kolata, panting with exhilaration, misleadingly titling her article: "Antibiotics Are Effective in Appendicitis, Study Says". Actually, no. Over a quarter of patients failed the proposed alternative treatment and required eventual surgery. That's bad. Like, what if someone wrote a paper saying that you could alternatively treat a heart attack simply with pain medications and a beta blocker and "only" 27% of patients would die within a year? Would this be cause for celebration? There are so many issues and problems with this paper I can only address them all using bullet points (bad for prose quality, of course, but keeps me focused).

In patient hospital stay and inconvenience to patients: When I do laparoscopic appendectomy on my patients, most are discharged home within 12-24 hours. The non-surgical treatment arm of the study spent 3 entire days in the hospital receiving IV ertapenem. Then they went home on a 7 day course of oral antibiotics. What is the cost of this? What is the effect on antibiotic resistance and development of hospital acquired c difficile colitis? What impact does this have on hospital bed congestion? Would you want to sit around doing nothing in a hospital room for 3 days?

Surgical technique: The authors of the study state that the reason they chose open appendectomy over laparoscopic surgery was that it was more representative of the surgical options world-wide, accounting for third-world countries without advanced laparoscopic capabilities. That's all well and good but the third world is rapidly catching up with the west. In the United States, 80% of appendectomies are performed laparoscopically and this number will only continue to rise as older surgeons from the pre-minimally invasive era retire. Laparoscopic appendectomy is well tolerated by young and old. I don't restrict activities after surgery. Most patients are back to work/exercise routines within a week. No one goes home with antibiotics after uneventful appendectomy. Infectious complications and pain perceptions are much lower compared with the open approach.

Non-inferiority??: The paper claims success because the medical treatment arm did not meet criterion for non-inferiority compared with appendectomy. And what was that criterion? Oh, it was a prespecified, arbitrarily chosen number of 24% that the authors just sort of picked out of thin air. Quite the low bar they have set. As long as we don't fail more than 25% of the time we can claim victory! Of course, the actual result of a 27% fail rate quoted in the paper exceeds the arbitrarily defined cutoff of 24%. But,---standard deviation, margin of error, p values, confidence intervals etc etc ( head explodes). Plus, "non-inferiority" is a bullshit, Orwellian sounding term.

Follow up limited: Patients treated medically in the study were only followed for a year. I guess that's fine if you are talking about a 88 year old guy with CHF and dementia. But what about the 22 year old? The 41 year old? Those patients presumably have a lot longer to go than one additional year of life. Not everyone will develop recurrent appendicitis, true. But what about other complications? I took care of a patient not too long ago who was managed expectantly with antibiotics for appendicitis a number of years ago. She presented with a bowel obstruction. She had never had surgery before. I had to explore her laparoscopically and the point of obstruction was due to a band of omentum stuck down against the cecum, creating an internal hernia. Underneath the omentum was a scarred, thickened, inflamed appearing appendix. I took her appendix out and lysed the adhesion. What about the rare case of appendiceal mucocele or even carcinoma that presents as "uncomplicated appendicitis"?

This paper ought not to change evidence based best practice guidelines. For uncomplicated acute appendicitis, the best treatment recommendation remains laparoscopic appendectomy, generally to be done within 24 hours of presentation to the hospital. There is a role for non-operative therapy. Some patients are simply not fit for surgery due to multiple co-morbidities. Some cases are equivocal for appendicitis, even after a thorough pre-operative work-up. Some patients are fully anti-coagulated with irreversible blood thinners and surgery has to be either delayed or deferred altogether. Sometimes a certain kind of patient will just adamantly refuse surgical intervention. But these cases ought to be the exception to the rule.

The lesson from the Finnish study unequivocally ought not to be: "We need to start presenting non-operative therapy as a viable, equally efficacious treatment option to patients we see in the ER with acute appendicitis." The paper actually makes the opposite argument than the one its authors would imply. Appendicitis remains a surgical disease. The best treatment is to get that useless, swollen, gnarled, rotten colonic appendage transferred from inside your body to the bottom of a metal kidney basin.

Previously I have voiced objection to some of the health policy pieces from the Harvard surgeon Atul Gawande. You can read old posts I had written in response to his viral sensation from the New Yorker from 2009, "The Cost Conundrum", here and here. I didn't like how the article attempted to place the burden of responsibility for spiraling American health care costs solely on the shoulders of unsavory, profit-driven physicians. The "culture of greed among physicians" was declared to be the enemy and politicians, health insurance and hospital administration lobbyists, Big Pharma, and medical device manufacturers lapped it up. Go after the foul, profit driven doctors, the article seemed to imply, and the problem will be solved. I thought it was an unfair, overly-simplified, factually inaccurate account of the reasons for health care spending in this country. Alas, I was essentially a lone voice in the wilderness. Before you knew it, President Obama was waving a copy of the article above his head as he decried the unscrupulous surgeons out there, lopping off "folks'" legs because they could earn $30 grand that way, rather than the lower paying "alternatives" like diabetes management. It was a surreal, absurdist nightmare display, from the perspective of a physician in the trenches. But it was too late for rebuttal. The debate was over before it even started.

Dr Gawande had another article in the New Yorker last month called "Overkill". This piece is ostensibly about the epidemic of unnecessary medical care that is carried out in this country. This ought to be a fairly uncontroversial proposition: we certainly do too many procedures, order too many expensive tests in the United States. The question is why. And Dr Gawande, in his latest high profile New Yorker piece, offers, um, a sorta rambling wreck of incoherence. We hear about a lady he saw in clinic with a thyroid nodule, unlikely to cause harm or shorten her life, that he tells her would be better off observed rather than sliced out. And he.....goes right ahead and books her for surgery. We read about a guy with back pain who, because of a corporate inside deal, gets to go see a neurosurgeon at a far away certified Center of Excellence for a 2nd opinion, and non operative therapy is recommended rather than surgery and he does well; the implication being that local physicians will always give bad, profit driven advice so you should unceasingly seek a specialist at major tertiary care centers (sorta like the one where Dr Gawande practices!) where all the doctors are magnanimous altruists who cry themselves to sleep every night with regret that they have to deposit a paycheck every 2 weeks for services rendered. We also read about his friend Bruce whose father fainted and, after an extensive workup was determined to need a triple vessel CABG. Unfortunately, he suffered a stroke during the surgery and was never the same. From this anecdote, he segues into a paragraph about a conversation he had with one of the hosts of the dorky public radio show "Car Talk" about how those Quik-E-Lube shops are always trying to "up-sell" the customer during an oil change on new air filters or windshield wipes or exhaust fans or serpentine belts. The analogy, I guess, is to nefarious doctors (like cardiac surgeons who consulted on Bruce's father) who... umm... do the same? Yeah, you have gallstones and RUQ pain. That's one thing. But you also have a right colon. Maybe that should be changed out too??

Gawande's article makes no mention of the deleterious effects of defensive medicine or the profit margins of so called "non profit" hospital conglomerates. It makes no mention of physician income decreases or the fact that most physicians these days are employees rather than entrepreneurial private practitioners. No mention about dwindling reimbursements for commonly performed procedures. No mention of medical device manufacturer profit margins. No mention of the fact that 30% of Medicare spending occurs in the last 6 months of a person's life (from a man who wrote "Being Mortal"!) Once again he treats health care spending in a vacuum, completely dependent on individual physician decision making. And once again, what drives that decision making is personal benefit and greed. It is unfair and incomplete. Now in real life I think Dr Gawande is actually a pretty cool, laid back guy. On Twitter he seems pretty chill. He likes decent bands. He seems to be intellectually curious, lacks the typical Ivory Tower mega-ego, is honest and open, etc etc. But in these pieces, he is doing a real disservice to his profession. With his cherry picked data and skewed anecdotal-based evidence, he makes it easy for the truly rapacious entities in American health care--- Big Pharma, Medical device makers, Hospital conglomerates, the Health Insurance Industry-- to unequivocally blame and demonize the very professionals who provide the bulk of actual value to our unwieldy system. I wish Dr Gawande would stop doing that.

Lionel Messi is unquestionably the greatest footballer of this generation and, arguably, the greatest athlete I have ever seen----apologies to Michael Jordan--- perform in his prime. Watch this goal from the Copa del Rey today:

This is quintessential Messi. One moment he is standing over the ball, in a seemingly harmless position at midfield, the next thing you know you are picking the ball out of the back of the net. How did this come to pass? How did things change so rapidly? When you watch it the first time it's disorienting. It makes no sense. How does that happen? Messi is 50 yards from goal. He is isolated near the sideline with a defender right on him. What the hell just happened? Then you watch it over and over on YouTube. After ten viewings it starts to make sense. After the 20th view, it all makes perfect, ineluctable sense. Of course, you think. What was all the confusion about again? 2+2=4, right? What else was he going to do? Watch it again. He gets the ball and pauses, daring his mark. Then darts to space with a burst to his right, beating his man. Two more defenders converge. He slows. He is triangulated by the defense, it seems. But no panic. It's a tight space; soccer in an elevator. No time to think. The ball is never far from his foot. He acts. A cutback. Another cutback, split the double team. Speed on a diagonal toward goal. Final cutback on the help fullback. Shoot low and hard, with left to right action, graze the post. Goal. Goal. Goal. Watch it again.

This is physical genius. It cannot be taught or learned. The chosen few are born with it, inchoate and undeveloped. They cultivate it. It is midwifed through the development stages and brought forth when mature, with a flourish, astoundingly. It takes our breath away. We can only watch and marvel. Before he mass marketed himself as a purveyor of schmaltzy pseudo-scientific pop psychology, Malcolm Gladwell wrote great piece back in 1999 on the neurosurgeon Charlie Wilson. In it, he compared the innate talents of Dr Wilson--- his sublime spatial recognition of anatomy, his precision in action, his confidence, his sudden Gestalt understanding of where he was and what needed to be done-- with physical geniuses in professional sports, like Wayne Gretzky and Tony Gwynn. The physical genius see things from a different height, a different angle. The game slows down. They have seen it all before in their imagination. Each jaw dropping, awe inspiring play is, to them, no big deal. They were simply reacting to a tendency they had seen before, a configuration of the defense that was all too exploitable, a slight sag of the defender's hips to the left. The physical genius sees and acts on a different level. And it happens so fast in their own minds they are reduced to explaining it with banalities. Well of course that's what I did. What else was I to do in that situation? He gave me the left sideline. The help defense came late and off balance. They underestimated the frontal attack. On their heels. It was easy, really.

The best surgeon I ever saw was this guy. Surgery, like soccer, is a game that requires intelligence, innate skill, diligent practice and dedication, and the gift of spatial imagination. Many surgeons can bring the first three components with them into the OR, but the last one remains elusive except for the select few. Every once in a while I feel that I have performed a laparoscopic cholecystectomy as effortlessly and masterfully as it could possibly be done, by anyone. Sometimes I feel this murmuring presence of beauty when i am operating. But those moments are fleeting. Most operations, at some point, swerve ever so slightly off course. I may have missed a visual cue. I failed to anticipate. A retractor is placed wrong. An obscured vessel branch is shorn. A placed suture is just off; you feel the overwhelming urge to re-do it. You fix it and move on. No harm is done. But the elegance is lost. A struggle ensues. I have to reconnoiter. Reset my lines of sight. See it again. Do it again. I have to grind my way through it. The narrative has been broken. The song skipped. A loud creaking noise from the house that awakes you from sleep. To see the best in action is a gift. Those who never deviate from elegance. Those who see the field from a higher stanchion. Whether it's Lionel Messi thundering down the right sideline or Alex Doolas chipping away at a frozen abdomen or Charlie Wilson whacking out a pituitary in 25 minutes, it is pure Art in motion. Joyce and Hemingway and Larkin and Cezanne have nothing on these guys......

Recently, a patient came in via the ER with jaundice and severe RUQ pain. The ultrasound demonstrated clear evidence of cholecystitis with stones and wall thickening and fluid around the gallbladder. The jaundice was the hang up. Obstructive jaundice in a patient with gallstones always raises the specter of choledocholithiasis (stones in the common bile duct--- CBD), which often requires a secondary procedure to address (ERCP). Well the gentleman got admitted in the middle of the night and when I saw him the next day, his repeat bloodwork revealed improvement in the liver function panel. Furthermore, his CBD was only 3 mm on the US. It seemed likely that if he did in fact have a stone in the duct, it may have already passed into the stomach. So, after consultation with the GI doctor, the patient was booked for a laparoscopic cholecystectomy, with plans to perform an intra-operative cholangiogram in order to definitively assess the duct.

This was late afternoon case. I popped in the umbilical port and insufflated the abdomen. Within 39 seconds I realized this was going to be a grinder of a case. The gallbladder was cloaked beneath a thick drapery of omentum, stuck up against the inferior edge of the liver. Ordinarily that omentum can be fairly easily swept away with a couple of quick maneuvers. But not this time. It was like someone had dumped a bucket of some epoxy resin in the guy's upper abdomen. The omentum wouldn't budge. Strand by strand I had to cauterize the plastered fat from the edge of the liver. Even that wasn't enough. The duodenum soon revealed itself, tented up against the undersurface of the liver. Again, a meticulous peel down dissection ensued. After about 45 minutes I finally saw the makings of actual gallbladder. Now the the gallbladder is usually egg-shaped or at least orb-like, with a tapering toward the cystic duct. This one was shaped more like a Cuban cigar--- long, cylindrical, and of a uniform diameter. The uniform diameter thing is a dangerous quality. We like difference and distinction in surgery, especially when trying to identify critical structures. A long thin gall bladder that fuses downstream with a common duct of equal caliber is frightening to the nth degree. And if only it were that easy. In cases of acute on chronic inflammation, the area of cystic duct/common duct confluence is a fused, woody, fibrotic sheet of adipose and scar tissue. Actual structures remain elusive. Strand by strand you have to slowly reveal the anatomy to yourself.

In tough gallbladder cases I use a principle called zoom in/zoom out. Yeah, it sounds dumb-- like some sort of faux-Zen, Pat Morita issued Karate Kid nonsense. But it works. It's all about attaining the proper balance between close up and far away. You need to be close. You have to see the structures. Each fiber of tissue has to be seen, categorized, defined. You need that camera right up on top of it all. But not all the time. Especially in biliary surgery, the most common cause of error (i.e. CBD injury) is a concept known as "visual perceptual illusion." The surgeon convinces himself that he sees what he wants to see. That strand of tissue he peels away has been defined in his mind. It's only scar, he thinks. A gestalt picture forms in his mind and the reality of the on-going operation is forced to adhere. That's how bile ducts get clipped and sliced. To avoid perceptual error---and the mind will construct an explanatory image spontaneously, you can't stop it from happening--- you have to shake it up, challenge the picture in your mind. Camera in, camera out. See from far, see near. The mind needs variety. Given limited information, it will construct a limited explanatory image. The most accurate representation of reality will occur when the mind is challenged, presented with a multitude of views and forced to reconcile them all. In and out. Push that gallbladder to the right and left. See the posterior space. This is how you do it safely.

The surgeon has taken care of the young man several times before. He gets admitted every few months with upper extremity abscesses, from heroin injections. He's a local kid. He grew up in the the old broken down east side neighborhood surrounding the hospital. His old high school is just down the street. He's 30 now. Usually, once the abscess is lanced he absconds from the hospital against medical advice (AMA). The surgeon has never seen him in the clinic for follow up.

This time he presented with a large area of induration and erythema in the upper arm. Small pinpoint scabbed areas appeared to be the epicenter of the inflammatory process. The surgeon recommended surgical debridement in the OR."I don't want to feel anything," the kid said."You won't," the surgeon replied. "You'll be asleep." "What about my pain now? That morphine doesn't do shit....""I'll take care of it. I can order the dilaudid. You'll get dilaudid and some percocet after the surgery."The young man shakes his head. "Yeah but that other doctor will change it. He always changes it. ""I'll put in the orders myself."The man won't look at the surgeon directly. He sits on the edge of the bed, eyes darting side to side, left leg pumping up and down off his toes. His face is sharp edged and narrow, not quite gaunt. His eyes never seem to open all the way, not sleepiness, rather a squinting distrust of the world. "Whatever man. It's always the same here. You all say the same thing.""All right man. Try not to eat or drink anything, ok? I'm going to try to get you on the afternoon OR schedule.""Whatever." He looks off into the nowhere distance. Clenched-jaw scowl and slumped shoulders. He looks like he may have been a wrestler (maybe 152 lb class) a long time ago. You could even convince yourself that he may have once even been handsome, a catch for some local girl----an athlete, one of the popular guys. But not anymore. Already a mouth full of blackened rotted out teeth. Scabs and scars running up and down his arms. Hair falling out in asymmetric clumps. A sheen of street filth permanently etched into the creases of his palms and fingertips. Those hollowed out eyes dark as holes.

In the OR, two small counter-incisions were made and purulence was liberated. The surgeon looped a Penrose drain through the skin openings and sutured the ends together. The wounds were packed and a Kerlix/ace bandage pressure wrap was applied. He received three phone calls that night from nurses about disruptive behavior and pain medication issues. Just give him another dose. I don't care if he just got some an hour ago. He needs more.

The next day, the surgeon saw the man pacing the halls around the nursing station. He wore his ubiquitous scowl. He stared down at the tiled floor as he marched, dragging his IV pole along like a disinterested caddy. He saw him out of the corner of his eye."Hey doc. Doc, I gotta get out of here. I have to be at an appointment at noon. ""I'll be in. I'll meet you in your room. I have to take down that dressing.""I need my medicine first."

The surgeon flagged his nurse and she drew up another mg of dilaudid. He gathered dressing supplies as she injected the patient. The addict perched uneasily on the edge of the bed, rhythmically bobbing forward and back. "Listen man, I have to be at my psychologists office by noon. It's part of the program. I don't show and I have to start all over again." "I understand. We should be able to get you out shortly. Let me look at that arm."

Very carefully the surgeon positioned the young man's wrist against his knee and then he started to cut away the layers of gauze and bandages with an old pair or trauma shears. He gently pulled the soiled dressings away like a split cast. He dabbed away the old clotted blood with moistened gauze. The cellulitis and induration had regressed markedly.

"Does it hurt like yesterday?""No. But I mean.... it will later. I don't need to be judged. I know what works. That tramadol doesn't do shit.""I'm not here to judge or not judge. Here, hold your arm higher. Let me put some clean bandages on."The surgeon reinforced the wounds with fluffed clean gauze and then he proceeded to wrap the entire upper arm with two rolls of soft Kerlix. "You don't need that ACE anymore. We'll get you some dressing supplies. I'll need to see you in the office next week. I'll remove the drain then.""Will that hurt worse than this?""No. That part is easy. ""Yeah. I'm sure. " he looked off over the surgeon's shoulder again, far away beyond the walls. "What's happening with you? This is no good, coming in here like this all the time. You ok? You have a place to stay?""No, man. Homeless. Sometimes the shelter. Sometimes my grandma's cousin lets me crash for a few weeks.""No other family? Mom or dad around here?""I don't get along with them. My family all had enough of me. They all judge me. I can't take it. And every time I tell some doctor I need some pain medicine I get judged and they send me out with the same useless shit." "No one in this room is judging you.""Maybe not you. Everyone else." He continued to bob forward and back, like a metronome. "I will make sure you have plenty of pain medicine. Those wounds hurt. I'll make sure you have enough to get you through the weekend. I promise. It's Easter weekend, you know. I know there's someone out there who probably misses you....who loves you. ""No." For the first time the man looks up at the surgeon. He squints his eyes like he's looking up at the sun. "No one loves me," he says. "I realized that a long time ago." "Nah. You're loved. We all need that. You don't have to fight it. You can fight everything else in life. But not that." The surgeon puts his hand on the young addict's shoulder. "Make sure you see me in the office. I don't want that drain getting infected because it's been in your arm for 3 months. Alright?""Yeah.""Be kinder to yourself. It's ok to hurt. I'm not here to judge any man's pain." The younger man looks down. His body goes still, at last. His eyes are closed. "OK," he whispers.The surgeon returns to the nursing station. He sits down to write out the prescriptions.

Catastrophe always lurks just around the corner in general surgery. The ER pages you, it could be anything. Most of the time it's about a bowel obstruction or appendicitis or a hot gallbladder or a hernia wreaking havoc---issues you deal with every day--- and an almost formulaic mindset is activated. Did you get a CT? NG already in? IV Zosyn please. Go ahead and admit to the regular floor. I'll be there in an hour. And then there are the calls where, 2 minutes into the conversation with the ER doc, you know you are going to have to cancel an elective case or reschedule your afternoon clinic patients to later in the week. Hypotensive, systolics in 70's, rigid abdomen, found down by roommate. We're pumping fluids in. Trying to get a line. WBC 25k, lactate is 13. You know a disaster has just landed on your doorstep and there's nothing to do but drop everything you're doing and go handle it.

The above images demonstrate a large amount of free air, especially in the lesser sac. A large fluid collection is apparent in the area of the pancreatic head. Mural edema of the right colon is obvious. You call the OR and make arrangements for emergency surgery. You open the poor soul's abdomen and immediately the odor overpowers everyone in the room. You encounter the foul dirty-dishwater fluid and fat saponification pathognomonic of necrotizing pancreatitis. The omentum is plastered to underlying structures encompassing the entire right side of the peritoneal cavity. Gentle finger fracture mobilization of the omentum reveals the catastrophe hiding beneath. Liquefactive necrosis of the hepatic flexure. Complete thrombosis of the vasculature in the mesocolon. You get into the lesser sac and bluntly debride the chunks of pancreatic necrosis, like blackened fragments of dirty curdled milk. The duodenum is mobilized and you find at least two well-demarcated holes in the lateral c-loop. The wall of the duodenum is thinned out, whitish, extremely friable. There's nothing to do here but damage control. The right colon is resected and an end ileostomy is fashioned. Pyloric exclusion to protect the duodeneum. Gastrostomy and jejunostomy tubes for decompression and feeding, respectively. Wash everything out. Put a zillion drains in. Close him up. Get him warm. Fluid and blood product resuscitation. Hope for the best....

A few months ago, I was seeing an elderly man in the hospital about a sigmoid mass seen on his colonoscopy that day. He had presented to the hospital with fatigue and anemia and the long meandering workup eventually zeroed in on this malignant appearing mass as the source. His daughter was in the room while I discussed the results, the likely diagnosis, treatment options, and anticipated complications. She was very engaged with the conversation and seemed highly informed. The questions she asked were advanced and sophisticated--- part Google search, part higher education background. Her mien was that of an eager person interviewing for a job she really really wanted. I liked her. She was earnest and serious about the situation at hand. She obviously loved her father. He seemed to defer much of the decision making process to her. He kept looking over at her with a faintly bemused expression. I was recommending surgery and he just smiled. What do you think, sweetie? Should I get this surgery? He looked like a man who would do whatever she said. He looked tired and worn down and it didn't matter about the cancer, all that mattered was doing what his daughter wanted. His eyes gleamed when he looked over at her.

I answered several of a series of her questions about the surgery proposed. Laparoscopy vs open. Potential complications. Expected recovery time. Need for radiation or chemotherapy. We went through it all, thoroughly. I was in there a good 45 minutes. It seemed she was coming around to the idea of having her father cut open, the tumor extracted. And then she said something that put me on my heels.

"Now....you're just a general surgeon, right? Will you be contacting a colon specialist to evaluate Dad for surgery?"

I just sort of stood there for a second or two, bewildered. But because this is not the first time someone has asked me this question over the years I quickly gathered myself. Before, I may have answered defensively. But not this day. I told her:

"Mrs Smith, I am indeed a general surgeon. And I appreciate your interest your father's care. Your love for him could not be more apparent. I assure you, that the surgical procedure I described for you falls well within the scope of my normal practice. I perform a lot of surgery for colon cancer and diverticulitis. And I think my results stack up with anyone around. That being said, I understand where you're coming from. There are some surgeons who do a fellowship in colorectal surgery after general surgery training. Those that do tend to make that an exclusive focus of their practice. I know several terrific ones here in town. I could connect you with one of them if that is your preference. I also would be happy to take care of your father's needs myself. You would get my best. "

She ended up staying at our hospital. The surgery went well and her father had a good outcome. I am a general surgeon and I have always taken great pride in that identity. Some days I have five hernias on the schedule. This past weekend I took out four gallbladders and drained a breast abscess. I see women with abnormal mammograms. I get IV access and manage patients in the ICU. I correct large diaphragmatic hernias. I drain butt pus. I whack out rotten appendices. I biopsy masses and see consults in the ER. I cover trauma call and take out smashed spleens. I operate early mornings and late at night. It is the life I have chosen. I knew what I was getting into.

But I have grown to wonder if the term "general surgeon" means what it used to mean. It started years ago when components of the general surgery repertoire began to fragment and separate from the main body. In the late 90's you were just as likely to have a general surgeon perform your carotid endarterectomy as a fellowship trained vascular surgeon. Nowadays, such a thought is risible. Vascular surgery itself has sort of branched off into its own universe, leaving general surgery far behind. Similarly, general surgeons have ceded much territory in the realm of endoscopy. In many small towns and rural settings, most of the colonoscopies may be done by a general surgeon, but it's rare in a larger city. Thyroidectomies are now being done by "endocrine surgeons". Breast lumpectomies get referred exclusively to "breast surgeons". Laparoscopic hernia cases get sent to the "minimally invasive fellowship trained" guy at the main campus. Melanoma goes to surgical oncologists or "Moh's dermatology surgeons".

In addition to the fragmentation of surgical practice into various specialties and sub specialties, alterations in surgical residency training programs have had unintended, undesirable consequences. The 80 hour work week restrictions, implemented over the course of 2004-2008 have led to a scenario where graduating chief residents are unfit for independent clinical practice. They haven't done enough surgery. They simply haven't spent enough time in the hospital. To wit:

Surgical fellowship program directors note that 30% of fellows were not prepared for operative cases and 2/3 could not work unsupervised for extended periods

Oral board exam failure rates have increased from 15% to 25% since work hour reform was implemented

The American College of Surgeons is very much aware of this burgeoning crisis and has taken steps to try and rectify matters. One idea is the concept of Transition to Practice (TTP) program. In this paradigm, graduating senior residents would spend a year as "apprentice surgeons" under the tutelage of some older, experienced surgeon with a broad practice scope. The hope is that this would help younger surgeons gradually grow more comfortable in a role as an independent practitioner rather than suddenly being thrust into the world without the necessary training or confidence. Further, since so many surgeons do a fellowship simply because they feel unprepared for an independent career otherwise, it is hoped that the TTP program will incentivize more graduating residents to pursue careers in general surgery. The impending shortage of general surgeons, especially in rural areas, would stand to be corrected by such an outcome. Mid sized cities could also stand to use a few more general surgeons--- and a few less hepatobiliary specialists sitting around waiting for the rare big cases.

I consider myself lucky. I trained at a busy residency program in Chicago and I completed most of my training before the work hour reforms kicked in. I graduated with a certain confidence that I would be able to step into a general surgery practice on day one. For me, there was nothing else to aspire to than to be a general surgeon. But with the way the training has evolved over the past 10-15 years I ought not be surprised when a patient asks me why I am not more. Perception is everything. For some reason, the idea of a generalist has become a derisive term. It wasn't always that way. I see myself as the last of a dying breed. I am a general surgeon. There is no shame in that....

A patient presented with 2 weeks of progressive right lower quadrant abdominal pain. His primary doctor ordered a CT which revealed the above findings. This was a very unusual case of cecal intussusception. In an adult, intussusception is always an ominous finding---in colonic intussusception, malignancy is the underlying cause in 50-71% of cases. In children, most cases of intussusception are spontaneous and unrelated to cancer and usually do not require surgical intervention.

This gentleman was admitted and a surgical consult was obtained. By the time I examined him, his pain was improving. We were able to perform a full colonoscopy which demonstrated a malignant appearing mass in the cecum. The next day he underwent laparoscopic right colectomy. Three days later he went home. In some respects, he was lucky to have developed an intussusception as it led to incapacitating symptoms, expediting the discovery of a malignant tumor.

JAMA published an opinion piece this month about the controversial issue of patients secretly recording their physicians during encounters. We live in the era of the smart phone. Everyone has one--- soccer moms, teenagers, young kids who can't even read yet, elderly nursing home patients who can't safely feed themselves. Everyone. And these devices have amazing powers of audiovisual capability. We all know this. Anyone can film or record anything at anytime. And most states have laws in place that allow for the secret recording of conversations between two parties, as long as one of the participants consents to the recording. The authors conclude:

If a physician suspects that a conversation is being recorded, that physician could handle the situation in several different ways that could benefit all parties. Doing so would first require that the physician be aware of the possibility of secret recordings. The physician can ask the patient if he or she is recording the conversation. Then, regardless of the answer, the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations. Taking such an approach would demonstrate the physician’s openness and desire to strengthen the relationship with the patient. The physician could also ignore any suspicions and provide care as he or she normally would without letting the possibility of recording affect either attitude toward the patient or medical decision making.

Unless federal or state laws change, physicians should be aware of the possibility that their conversations with patients may be recorded. If physicians embrace this possibility, establish good relationships with their patients, provide compassionate and competent care, and communicate effectively and professionally, the motives of patients and families in recording visits will be irrelevant.

Personally, I don't have much of a problem with being secretly recorded, either by a patient or someone else in the room. I wouldn't feel violated. I don't see it as undermining my relationship with patients. In this era of less paternalism in medicine, I think patients just want to feel that they have understood the issues and are able to arrive at informed decisions based on the available information. Medicine is complex and unwieldy. Patients get overwhelmed. In many physician/patient encounters, given the emotional content and the stakes involved, communication gets compromised. Meanings are lost. Words are misheard. Opinions get misinterpreted. And patients feel that by simply recording the encounter, all those issues will dissipate. Of course, it isn't so simple. Not much will be gleaned from re-listening to a garbled audio recording of a physician's thoughts. At least not as much as just speaking with the physician one on one again, to reinforce ideas and clarify issues. A physician should always be prepared to repeat himself, both within the context of the initial encounter, and at subsequent encounters, either on the phone or in person.

There is one caveat to this. Any recordings of my role as physician would have to be done without my knowledge. It would be essential that secrecy was preserved. The minute you tell me that you are recording me, the encounter immediately gets transformed, irrevocably. Suddenly, it is no longer authentic communication between two humans, one of whom is trying to tease out the source of what ails the other. Instead the encounter has become mere performance. Instead of assuming my role as "doctor" seeking to alleviate suffering, I have become a man up on stage, microphone in hand. If I know I am being recorded it would just make me self conscious and awkward and stultified, worried more about banalities of diction/syntax/voice timbre/modulation/how goofy i may sound upon repeated listenings etc etc. An honest, authentic, meaningful physician/patient encounter requires a certain form of self-effacement, a losing of oneself in the moment. Something happens when you truly and concertedly give yourself over to the hard work of listening to a vulnerable human who is trying to convey pain and suffering. At some point, the gap between two strangers is bridged. I suppose this is called empathy. But it cannot be contrived or faked or staged. For me, at least, recording that intimate encounter would ruin everything. So much would be lost, just to preserve a few more words.

The other issue I draw a line on is as follows. Patient may have a cousin in Idaho who is a pulmonologist. The patient takes out cell phone, calls the cousin doctor as I begin my exam, and places said phone on bedside table. "Do you mind? My cousin is the only doctor in our family and he wants to hear everything you say". I tell everyone the same thing. I don't "do" conference call examinations. What happens is, the person on the other end of the line can't hear what I'm saying and they ask me to repeat this or that. So I'm always stopping and starting, shouting toward a faceless voice on a phone. I have to turn my head away from you, the patient. It gets annoying. I lose my rhythm. The whole encounter gets chopped up and fragmented. It's unsatisfying on both ends. I'd be happy to call your cousin as soon as we are finished and convey to him my exact thoughts via a private phone conversation.

With Match Day having come and gone last week, I thought now would be a good time to re-post an old essay/rambling mess I wrote back in 2010 on my old blog site. It's about JD Salinger and fresh young doctors, somehow....Jerome David Salinger died a few weeks ago at the age of 91. The famously reclusive author who chronicled the fictional exploits of Holden Caulfield and the precocious Glass children last published a work of fiction in the mid 1960's. For the past 40 years he has lived an anonymous, unassuming life in New Hampshire. I mean can you imagine an author/artist/actor at the top of his game in this day and age suddenly withdrawing from the public eye, never to be seen again? Rumor has it that Salinger never stopped writing, that his private archives contain volumes of unpublished material.

I'll get this out of the way in the beginning---I'm an unmitigated devotee of J.D. Salinger. I've read everything he ever wrote, multiple times. There's something slightly embarassing about that fact, I realize. Especially at my age. At the beginning of Hemingway's "The Sun Also Rises", Jake Barnes describes how Roy Cohn read a book called "The Purple Land" too late in life and was corrupted by its sentimentality and romanticism. Many say the same about Salinger's "The Catcher in the Rye". You're supposed to read it when you're a teenager, so you can identify with the adolescent angst and sense of betrayal that dawns on a young sensitive soul when he realizes the world is full of selfish phonies, but then you move on, to richer, more nuanced literary takes on human existence. It isn't meant to be a book for a mature sensibility; if anything it can be dangerous to read it when you're into your twenties. I gently disagree. It's a soulful, meaningful book that I plan on reading many more times before I die. I read about Holden Caulfield and Franny and Zooey and Seymour and all the other Glass children for the first time when I was 23 years old. I was living in my mom's basement, working at a lousy plastics factory during the day, waiting to find out if one of the medical schools in Ohio would accept me. I wasn't exactly feeling too enthusiastic about my future prospects. My friends had all seemingly moved on in life, consulting jobs and grad schools and such, while my life had stalled for the first time. Reading Salinger that year kept me sane and hopeful I suppose. When the phone call came in the early summer announcing that I had been accepted, I drove around like a madman, happy and delirious, sort of like Holden at the end of the novel, crying in the rain as he watched his little sister Phoebe spinning in circles on the Merry-Go-Round in the park. I couldn't exactly articulate why I was so happy, at that point. I had been chosen was all I knew. Chosen to embark upon a life of service and honor. And all that jazz. I think all medical students start out that way, wide eyed and humble and full of idealistic hope. But it doesn't last; life rolls on and consumes you and the next thing you know you're anxious about grades and AOA status and what specialty to pursue and which residency program to apply to and all these things that have nothing to do with Phoebe on the Merry-Go Round. Without losing those moments of inchoate happiness completely, a young doctor has to somehow figure out how he's going to go about fulfilling his promise to himself, his profession, and his patients. How should he go about being an actual doctor? With what mindframe ought he to adopt? Ecstatic joy is no match for the cruel grind of actual existence, the years on top of one another, the petty torments of human aspiration. You need a more enduring strategy.

There are talented, intelligent college students right now across this country considering whether or not to make a run at medical school. Nowadays, it isn't the slam dunk decision it used to be. If you were smart, top ten in your class, Dean's List--- medicine automatically went to the top of the list of possible career options. It had prestige. It paid well enough and possibly even better depending on what specialty you chose. It made your parents proud. It represented a low risk path to legitimacy in life, an assurance that your social standing wouldn't be contingent on such factors as personal relationships or fluctuations in the business cycle or mere chance. It just seemed to be a smart, conservative thing to do for an otherwise intelligent, hard working youth who harbored vague aspirations of "helping people".

Well things are getting ugly in New Hampshire, of all places. The state legislature just voted to end the ACA-derived Medicaid expansion (available as a federally funded option to all states) beyond the year 2017, thereby throwing tens of thousands of vulnerable poor citizens into the stressful chaos and financial uncertainty that defines being an adult in America without health insurance. This quote from Republican state representative Dan McGuire was particularly uninformed and odious:

“Expanded Medicaid is a huge disincentive for people to work,” said Rep. Dan McGuire, R-Epsom, who voted to let the expansion sunset at the end of 2016.

“There wasn’t a lot of debate on it. Traditional Medicaid is designed to benefit people who are deserving of charity due to conditions beyond their control. Expanded Medicaid benefits people who are undeserving of charity. These are people who don’t have any reason for not working.”

Those are just delightful sentiments, aren't they? It seems that, in the world of Representative McGuire, the only acceptable excuses for being on Medicaid would include "Struck down by thunderbolt from the hand of Zeus", "Limbs gnawed off by sharks", "Earthquake destroys town", "Typhoon washes away all manufacturing employers in 50 mile radius" and "Abducted by aliens". Mass unemployment, economic stagnation during the Great Recession of 2008-2011, and off-shoring of industrial and manufacturing jobs over the past 30 years are irrelevant, inconvenient details.

I love how Mr McGuire seems to think that "having a job" eliminates all worries about health benefits. I think all of our Wallmart and McDonald's workers forced to accept 25 hour work weeks would have something to say about that assumption. It's as if the working poor don't even exist in his worldview. Anyone qualifying for Medicaid must necessarily be a lazy, unmotivated, entitled slug who would prefer to sponge off more successful, more "authentic" Americans. It doesn't even cross this guy's mind that there are plenty of struggling Americans working several jobs--50, 60, 70 hours a week-- but don't have health insurance, either because they are part time at all those jobs or the company doesn't even offer benefits, and they are unable to purchase individual insurance because it's far too expensive. Furthermore, this bill they passed only eliminates the Medicaid expansion, i.e. those who incomes fall within 138% of the poverty line. It has nothing to do with basic Medicaid itself. This expansion only applies to those people who are already working but earn too much to qualify for regular Medicaid. This has nothing to do with freeloaders choosing to stay at home and play X-Box stoned all day. The whole thing is just about as disgusting and cynical and deceptive as you can imagine.

The richest, most powerful country in human history. That's not hyperbole. And yet the provision of affordable health care for its citizenry remains an unsettled political powder keg. It remains a dark stain on our collective moral standing....

Chris Borland, a linebacker for the San Francisco 49ers, announced his retirement from the NFL this week. Borland had a reasonably productive rookie year and was expected to play larger role in the team's defensive schemes this coming season. Most analysts expected he would be one of the team's starters. So why would an otherwise healthy, productive, up and coming player walk away from such a once in a lifetime opportunity? Apparently he got his bell rung during training camp last August but didn't tell anyone because he was a rookie trying to make an impression. Afterwards, the experience gnawed at him and he did a little private independent research on repetitive head trauma in NFL players. A portion of Borland's statement:

"I just honestly want to do what's best for my health," Borland told "Outside the Lines." "From what I've researched and what I've experienced, I don't think it's worth the risk."

So yeah. On the cusp of stardom, his dream job in hand, the dude walks away because he didn't want to end up like Junior Seau and Dave Duerson and Jovan Belcher and Justin Strzelcyzk and Terry Long and Chris Henry and Andre Waters and Mike Webster and Tony Dorsett and Ray Easterling and John Mackey and Gene Hickerson and Ted Johnson and Owen Thomas and 17 year old Nathan Stiles and on and on and on. The now well-described ravages of Chronic Traumatic Encephalopathy (CTE) gave him pause, and he justifiably flinched. And he walked away while he still had the cognitive wherewithal to do so.

The NFL responded as follows:

By any measure, football has never been safer and we continue to make progress with rule changes, safer tackling techniques at all levels of football, and better equipment, protocols and medical care for players. Concussions in NFL games were down 25 percent last year, continuing a three-year downward trend. We continue to make significant investments in independent research to advance the science and understanding of these issues. We are seeing a growing culture of safety

This is a deeply misleading, cynical statement. The consensus opinion of scientists and doctors is that CTE represents a chronic degenerative brain injury that occurs after the accumulated effect of repetitive head blows, both minor and major. Whether the traumatic event qualifies as a concussion or not is irrelevant to the pathophysiology of CTE. And the NFL knows this. The NFL is a craven, exploitative, multi-billion dollar monopolistic industry that spits out broken shells of men when they have out-lived their usefulness. But at least we have been entertained.....

Like most of my age cohort, I was brought up to believe that the Great Satan threatening to undermine the bloated American healthcare system was our broken-down, antiquated, self-interested model of reimbursement for care provided called "fee-for-service". Being a professional who, to the best of my ability, tries to maximize the value of the care I provide to my patients, I subscribed wholly to the notion that the cause of our exploding healthcare cost conundrum is driven entirely by me and my physician brethren. We order too many tests and perform too many procedures. We do this because we are motivated by greed and profit. The financial incentives to do more, to pad our bank accounts, to renovate the spare bedroom in our Cayman Island vacation homes, to rip out the tiles in our master baths and replace it all with gold embossed marble, to book a window seat on the next Space X shuttle to Mars, to become minority owners of professional sports teams, simply drives us to do more and more and more, whether our patients need it or not. Ask not if the patient needs a new Stryker mechanical joint, rather ask "does the patient have knees". We have been told this time and again. Battered over the head like the self-obvious cudgel it ought to be. To wit:

Kaiser Family Foundation: "Most insurers — including traditional Medicare — pay doctors, hospitals and other medical providers under a fee-for-service system that reimburses for each test, procedure or visit. Coupled with a medical system that is not integrated, this encourages over-treatment, including repetitive tests, the report says"

Robert Wood Johnson Foundation: "Accordingly, reimbursement under a FFS model generates a strong incentive for a high volume of tests, procedures, inpatient stays and outpatient visits, including those that have questionable potential to improve health. The incentive to generate income by performing more tests and procedures is exacerbated by having the costs typically paid by third party insurance, masking the true cost to consumers. "

Ron Wyden: "Pay-for-procedure or fee-for-service reimbursement rewards doctors and hospitals for volume - not keeping patients healthy or being efficiency. Pay-for-Performance is clearly one tool that can change the incentives to reward quality."

CBS News: "A systemic driver of high costs is America's fee-for-service healthcare system, in which providers are compensated for each procedure, not for the outcome of care. This system provides providers an incentive to pad their bills by performing as many services as possible, while providing no incentive for patients to decline unnecessary procedures"

Center for American Progress: "One of the key reasons for the high level of health care spending and its rate of growth is the predominance of the fee-for-service payment system, which rewards quantity over quality, especially for high-cost, high-margin services"

It seems clear enough. Physicians collectively have betrayed their constituents. We, as a professional guild, have yielded to crass, craven materialistic pursuits. The way of the future is the "Accountable Care Organization", an amorphous hive-mind of specialists and sub-specialists who act in concert, an intellectual symphony of elegantly intertwined collaborators who then split up the paltry reimbursements like Trappist monks dividing the fall harvest for winter sustenance. Further, the dawn of of the Age of "Value based Purchasing" is upon us. Remuneration will become 80-90% "outcomes-based". Are you opposed to paying only for quality? Then you must agree that it is immoral, heinous, unconstitutional even, to pay for a medical intervention or treatment if the outcome does not lead to complete restoration of optimal health within 30 days. You must. This is not debatable. There are bounds to the limits of what is considered acceptable discourse in the realm of health care reform.

Sure there are inconvenient facts that only seek to cloud the One True Perception of what is wrong with American healthcare. Facts can be propagandized. Truths outside the parameters of "TRUTH" will not be tolerated. The following will be used by the undesirables to bolster claims of innocence and cynically direct one's attention to other targets of cost-containment:

Reimbursement for general surgical procedures, like inguinal hernia repair, have gone down 20-30% (in nominal dollars) over the past 15 years

The fact that 30% of Medicare spending occurs in the last 6 months of a patient's life

The opacity of the "Hospital Chargemaster" and variability in reimbursements from state to state, town to town.

Disregard all the above. It only serves to distract from the true villainy occurring every day in individual physician offices and operating rooms. The true test of a physician's character depends on his or her willingness to forgo personal remuneration for services rendered. All compensation ought to be contingent on the final outcome. Only by disconnecting the physician from any tangible financial benefit will we enter the Utopian era of Value Based, Collaborative healthcare provision. After all, the rest of the economy functions along similar lines. No one pays their plumber to come out to their home for a leaky faucet. That's absurd. We all pay a set, reasonable premium every year for "Household Expenses" which covers your plumber, heating and cooling guy, roofer, various approved handymen, contractors, etc. And if another pipe, in the other bathroom springs a leak within 60 days, well, that plumber shows up upon demand to fix it sans additional charge. This is how we control costs. we simply stop paying for services rendered. Because physicians are only out to get into your wallet. They will not stop. Without an aggressive counter-attack they will continue to bill you for that 4AM appendectomy, for working up your chest pain, for diagnosing your breast cancer. The world has moved past such depravity. We have arrived at the precipice of disaster and, looking over the edge, a Paradise extends interminably before us. I see a world with only healthcare "providers" rather than the unnecessary hierarchical declination from "doctor" to "midlevel practicitioners". I see bundled reimbursements and capitation. It is a Brave New World of "Patient Centeredness" and "Accountable Care". Physicians must fall into place and accept their role as interchangeable pieces, like ever so many Ford workers on a modern assembly line, contributing a small widget to the glorious whole. The new way strides forth with ineluctable momentum, with or without us....

An elderly lady presented to the ER with sudden severe RLQ abdominal pain. A CT scan was ordered because of concerns for acute appendicitis. Did she have appendicits? No she did not. That amorphous, dark glob you see is actually the patient's gallbladder, down below the level of her anterior superior iliac spine. We corrected her INR and took to surgery. Asleep and anesthetized on the table you could feel the firm mass down in the right lower quadrant. "You'll have to stick one of your ports in her upper thigh", my assistant quipped.

Upon insufflation we encountered a massive, gangrenous gallbladder just sort of floating around on the right side of her abdomen. Completely unfixed from the liver it seemed, as if someone had already been by to remove it but forgot to extract it at the end of the case. With a little manipulation I was able to detorse the rotten sac and flip it over the liver. It had twisted around the axis of the cystic artery. I placed a couple of clips on the the important structures, bagged it, and drew it out of her forever. 90% of her gallbladder was completely untethered to her liver bed.

Gallbladder volvulus is a pretty rare phenomenon. 300 or so cases have been described in the literature. You can read your little heart out here, here and here. Most patients are elderly thin females. The pathophysiology under girding the disease is a poorly fixated, completely peritonealized gallbladder. Most of the time, a large percentage of the back wall of the gallbladder is adherent to the liver. This seems to fixate the GB pretty well and prevent unwelcome contortionist maneuverings. as above. In the elderly, loss of fat and general atrophy of tissues may contribute. The lady felt much better afterwards. She went home in a couple days, albeit unhappy about the hospital food. The fry had been dry. Who doesn't know how to cook fish?